Healthy Redefined Part 1: Measuring the Obesity Crisis

Georgia’s “Strong4Life” Fat-Shaming Ad. “It’s hard to be a little girl when you’re not.” Note: This young girl does not have any of the health problems the campaign is working to fight.

From unfortunate fat-shaming in Georgia’s “Strong4Life” campaign put on by Children’s Healthcare of Atlanta to kids being graded on their weight in public schools across the country via their BMI score on their report cards, we see well-meaning people using harmful and ineffective strategies like crazy to try and counteract this country’s weight problem. This overwhelming focus on body size has stolen the spotlight in mass media and scholarly research since the mid-‘90s, all citing an imperative to end an obesity crisis that has been championed by the federal health agencies.

With the health and fitness of the nation as the key justification for calling high levels of obesity a “crisis,” it is important to understand how bodily health is defined in research. How is health measured? What defines a healthy or physically fit body?In a country where both obesity and eating disorders have skyrocketed simultaneously, it is crucial to understand how physical health has been and is being understood, tested and promoted.

Scholars are concerned that very little evidence has been produced regarding the question of exactly how body fat is supposed to cause disease (1). With the exception of osteoarthritis, where increased body mass contributes to wear on joints, and a few cancers where estrogen originating in adipose tissue may contribute, causal links between body fat and disease remain hypothetical. Researchers are asking health professionals and policy makers to consider whether it makes sense to treat body weight as a barometer of public health. Despite this shaky foundation for defining physical health in terms of body fatness, much of current health and communication research measures health through simple measures of a person’s body fat, and that may be doing more harm than good for the health status of this country.

Defining Health: Body Fat = Body Health?

Researchers measuring health in terms of body fat generally rely on the American Council on Exercise’s guidelines to determine which percentages are healthy, with anything below 10% and above 31% in women (or below 2% and above 24% in men) considered a health risk. Direct measures of body composition estimate a person’s total body fat mass and fat-free or lean mass through MRI, underwater weighing, CAT scan, and other methods. Power, Lake & Cole (1997) said, “an ideal measure of body fat should be accurate in its estimation of body fat; precise, with small measurement error; accessible, in terms of simplicity, cost and ease of use; acceptable to the subject; and well-documented, with published reference values.” They go on to state that “no existing measure satisfies all these criteria.” Since these methods are expensive and invasive, they are rarely used in research. Because of this, scholars are much more likely to rely on indirect measures of body composition, including the most popular of them all: Body Mass Index (BMI).

Indirect techniques for measuring fat include all the most common ones: waist and hip measurements, skinfold thickness, and indexes of measured height and weight such as BMI. These measurements are only a surrogate measure of body fatness, yet they are commonly used to represent not only adiposity but also health and fitness in research and media discussion about healthy bodies. The life and health insurance industry, medical practitioners, researchers, health specialists and seemingly everyone else on the planet uses the BMI to measure people’s health. That’s because it is the international standard for judging healthy weight, as upheld and promoted by the CDC, NIH and WHO. This is bad.

Here are 10 quick reasons why the BMI is a shockingly terrible measure of health:

The equation used to calculate BMI (the ratio of an individual’s weight to height squared) was developed in the 19th century by Quetelet, a French scientist who warned the calculation was only meant to be used for large diagnostic studies on general populations and was not accurate for individuals.

The BMI’s height and weight tables used to tell you what your score means came from the life insurance industry. Yep. A standardized table of average weights and heights was developed first in 1908, when life insurance companies began looking for ways to charge higher premiums to applicants based on screening by their own medical examiners. By setting the thresholds for “ideal weight” and “overweight” lower than what mortality data showed as the actual healthy weight ranges, they were able to collect more money for those they deemed “overweight.” In 1985, the NIH began defining obesity according to BMI, which defined the 85th percentile for each sex as the official cutoff for what constitutes “obese,” based on the standards for underweight, average, overweight and obese that were set by the 1983 Metropolitan Life Insurance Company mortality tables (Williamson, 1993).

The NIH implemented the BMI standard under the theory that it would simply be used by doctors to warn patients who were at especially high risk for obesity-related problems (2). It was never meant for individuals to calculate their BMI and accept it as a diagnosis of whether or not their weight is healthy, yet that is EXACTLY how it is used today. Individuals are encouraged to easily diagnose their own BMI status through the NIH website-hosted BMI calculator.

Those weight tables are based on the unfounded idea that any weight gain after age 25 is unhealthy. Though weight tables before the mid-1900s allowed for increasing weight with age (which naturally occurs), the Metropolitan Life insurance Company became the first to deem an increase in weight after age 25 as undesirable and unhealthy – again, to collect higher premiums. Also, the BMI is advised to be used only for people older than 20, due to the changes young bodies undergo before that age, yet it is very often used to diagnose adolescents and teens. Researchers admit that it is unclear at what level of body fat health risks begin to rise for children (Denney-Wilson et al., 2003), so trying to define a standard of what constitutes overweight and obese for children is incredibly difficult.

Those weight tables also did not take into account body frame or build, unlike previous tables, which included “small,” “medium” or “large frame” due to demands from physicians who rightfully wanted to avoid serious miscalculations of body fat (Cziernawski, 2007).

Those same 1983 tables (and now our BMI) also failed to take gender into account, despite healthy levels of fat and weight distribution differing greatly between males and females (3).

BMI is based on a Caucasian standard. It is proven to be highly inaccurate for other races and ethnicities. In particular, in some Asian populations, a specific BMI reflects a higher percentage of body fat than in white or European Ppulations (James, 2002). Some Pacific populations and African Americans in general also have a lower percentage of body fat at a given BMI than do white or European populations (Stevens, 2002). Even the WHO has acknowledged the extensive evidence that “the associations between BMI, percentage of body fat, and body fat distribution differ across populations” (WHO, 2004).

In 1998, millions of people considered of “normal” weight were suddenly re-classified as “overweight” the next day when the NIH lowered the threshold for “overweight” and “obese” by 10 lbs. They based this change on the vague claim that studies linking extra weight to health problems warranted the changes (Cohen & McDermott, 1998). On June 16, 1998, the “average” woman was 5 feet, 4 inches tall and weighed 155 pounds. On June 17, a woman of that same height and weight became “overweight.” The requirement for “average” dropped 10 pounds to 145, and a person of the same height who weighed 175 pounds was considered “obese.”

Experts say it’s “useless.” Dr. David Haslam, the clinical director of Britain’s National Obesity Forum, said, “It is now widely accepted that the BMI is useless for assessing the healthy weight of individuals” (4). Despite extensive evidence proving the BMI lacks accuracy for calculating an individual’s body fat (4), A growing pool of evidence suggests that BMI is a “crude tool” for judging individual health that “fans fears of an obesity epidemic even as it fails as a reliable measure of an individual’s health” (Heimpel, 2009). Even the U.S. Preventive Services Task Force concluded there is insufficient evidence to suggest BMI screening can be used to prevent adverse health outcomes (4). Prentice & Jebb (2001) illustrated a wide range of conditions in which “surrogate anthropometric measures, especially BMI, provide misleading information about body fat content, including infancy and childhood, aging, racial differences, athletes, military and civil forces personnel, weight loss with and without exercise, physical training and special clinical circumstances.” More and more studies are showing the fact that people in the “overweight” and even “obese” categories of the BMI are at much lower risk of death than those in the “underweight” and even “normal” categories. So why do we keep measuring health based on BMI?

Despite all the evidence against it, government health agencies defend the BMI as the national standard for judging healthy weight due to the fact that it is “inexpensive and easy for clinicians and for the general public” (CDC, 2010). That’s exactly why researchers use it so consistently as a stand-in for “health.”

It is imperative to keep in mind that the much-publicized U.S. obesity crisis has risen to the forefront of national attention only since the late ‘90s, after the NIH changed the standard for what constitutes overweight and obesity. Using data gathered from 1976-1980 and comparing it to data from 1999-2002, the CDC reported that obesity doubled from 15 to 31 percent between 1980 and 2002 (CDC, 2007). It is unclear whether the data was compared using the same standard for determining “obesity,” since the criteria for fitting into this category changed in 1998 to include many more people that were previously considered merely “overweight.” Though obesity remains at the forefront of national health concerns and media discourse of Americans’ health, the rate of obesity hasn’t changed in a decade. It plateaued since the most recent CDC report, with no change between 2003 and 2006, when the most recent national data was gathered (Heimpel, 2009; CDC, 2007).

Unfortunately, heart disease, cancers and diabetes remain serious threats to public health, and obesity is considered a risk factor for these chronic illnesses. So if the BMI is worthless, then what do we use to measure or determine bodily health? The No. 1 step is to quit measuring and start exercising. That brings us to the incredibly important Part 2 of this Healthy Redefined series. But if you just can’t stop measuring, one step in the right direction is just as easy to calculate and much more accurate than BMI: waist circumference (WC). It is a more specific marker of upper body fat accumulation than BMI and is correlated with lipid abnormalities (O’Connor et al., 2008). When the researchers were evaluating a weight management program for overweight and obese adolescents, O’Connor et al. (2008) found a significant decrease in waist circumference, but not BMI, in participants. Janssen et al. (2004) evaluated WC in assessing obesity-related health problems and found that waist circumference is more effective than BMI at explaining obesity-related health risk. They found that people who are overweight or obese according to the BMI often have the same level of health risk as normal weight people with the same WC value.

Though WC is a step in the right direction and closer to measuring health, it still isn’t quite there. The next step is to redefine what this crisis is really about. It’s about health, not body size. During the time the obesity crisis has been in the forefront of media and federal health agency initiatives, the diet and weight loss industries have thrived unlike ever before. Simultaneously, fat-shaming/thin-ideal-promoting media have also flourished, with female body image hitting an all-time low. With lost self-esteem, lost money and time spent fixing “flaws” and a well-documented preoccupation with thinness among females of all ages, the effects of profit-driven health information involve serious loss for women, while too many industries see huge economic gains. From the life insurance industry collecting higher premiums from those they deem “overweight” based on a standard they set themselves, to major financial savings for medical experts and the government using the profit-driven BMI, to the diet and weight loss industry raking in more than $61 billion on Americans’ quest for thinness in 2011, those who make money off the discourse surrounding women’s health are thriving unlike ever before.

With so much evidence showing that our obsession with body fat is missing the mark for health and well-being of all sorts, I argue that we need to do away with the title “obesity crisis” all together. This crisis isn’t about too many people meeting an arbitrary standard of body fat, this crisis is about poor health due to unhealthy choices defined most prominently by inactivity and poor diet. Measuring health according to activity level is the most promising step for getting an accurate gauge of true wellness. But FIRST, we must focus on getting rid of barriers like “feeling too fat to exercise” and not knowing if you can be successful in order to make way for real success! Next Up — Healthy Redefined Part 2: Forget Fat and Get Fit!

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The categories of weight chart is terrifying…why does “normal” look like a skeleton? As an overweight student, I face judgments almost daily from my peers and my instructors. I want to be better than that and I want to understand what my future-patients are going through. I love your site!!

THANK YOU!!!!! The same way its hurtful to attack someone who may be a bit larger its just as hurtful and damaging to insult and attack someone who’s thin. I’ve spent my entire life being called annorexic and its not exactly a nice feeling. I mean now every time i look in the mirror i can’t find anything that I like about myself because all i can focus on is that I feel like i look like skeletor!

Looking at the categories of weight chart, I first thought that the one on the left would be underweight, and the one considered overweight would be normal. It is absurd that at 5’4″ and 140 lbs., I am borderline overweight. BMI needs to go away.

my husband has always scored as overweight on the bmi charts even though he is incredibly fit (he is a cyclist and runner.) His arms are the length of a man who is 6 ft tall even though he is 5’8. I think his long torso and arms mess up the “calculation”. At any rate I enjoyed reading your 10 bits of evidence as to why the bmi is such a bad tool esp. since I’ve seen in my own household how terrible it is!

Can I get a reference for the statement “…this crisis is about poor health due to unhealthy choices defined most prominently by inactivity.”? As far as I’ve understood journal articles I’ve read, physical activity serves as a daily buffer but, but diet tends to be as a dominating source for “obesity” related disease.

That statement was referring to the health problems referenced (heart disease, high blood pressure, type 2 diabetes) – not obesity. The bulk of those references listed at the bottom back up the fact that regular physical activity either solves or greatly improves those issues – as you know as well as anyone! Diet is most definitely a huge factor in obesity, as well as diseases that include obesity as a risk factor. (I should have added “poor diet” into that statement from the beginning – and it has now been added, thanks to your reminder.)

Experts tend to classify high blood pressure, heart disease, and Type II diabetes as “obesity related diseases”, all which should be approached through a hybrid of diet and exercise. While I agree with your claims of BMI, I am nervous that the general public doesn’t understand that “obesity”, from a professional health standpoint, is typically limited to disease prevention.

There are literally dozens of huge epidemiological studies that show cardiorespiratory fitness moderates the relationship between weight and poor health outcomes. In English, if you’re fit, your weight doesn’t matter! And we’re not talking about running marathons here – just basic fitness needed for daily life. Not huffing and puffing up the stairs, for example.

Hey guys – this is one of the BEST BMI research summaries I’ve read in ages, and I’ve probably read dozens while studying for my field exams, etc. I hope you pass it around the blogosphere like crazy! (actually… do you mind if I re-post sometime?) Keep fighting the good fight!
XO,
Kjerstin

Thank you for publishing this article. I understand you have analytics and data to back you claims, so what I am about to say is relatively insignificant as a data set. I was fat my whole life (I am 32). Shame was the only thing that worked. I felt horrible about who I was and how fat I was. Shame was the only thing that did it. I knew the risks, I understood the data. But it was not fitting into clothes and breaking chairs that did it. I don’t think shame is bad. It might not be for everyone, but its very effective for others.

Just as an FYI– that bmi “better for business” graphic is an advertisement for the airline, British Midlands International. (They’re fairly small–if you haven’t been to the UK you probably have never heard of them.) I’m not sure whether this is an editorial oversight on your part or a deliberate attempt to decontextualize the image, but that logo and statement have absolutely nothing to do with the body mass index. There is no claim there, implicit or otherwise, that using BMI as a health metric has any bearing on business… It’s about airplanes. If it was unintentional: you should have better fact-checkers! And take the picture down. If it was intentional… that’s sleazy! And silly!

Thanks for letting us know, Katie! I thought it was just a clever graphic someone made and wasn’t able to find a source for it, but that’s interesting to know it’s from an airline. Please note that I’ve added that info to the caption. The slogan is incredibly pertinent to this BMI conversation, even though it’s about airplanes, which is why I included it in the first place. Rest assured there’s no intended sleaziness or silliness about our use of the image.

Thank you so much for this. I am a 17 year old girl, and i am a size 16. I eat very healthy (lots of fruit and veggies, whole grains, avoiding super fatty meats and deserts) and, while I’m no Jillian Michaels, I exercise regularly. (Long walks with my dog, dancing, and yoga) I weigh a lot, and every time I go to the doctor’s for a check-up, they say the same thing: Lose Weight. I ask them every time: “How’s my blood sugar level?”
“Fine.”
“And my blood pressure?”
“Perfect, actually.”
“I eat healthily and would have no trouble running a mile without getting winded.”
“Still. It’s not healthy for a girl your age to be so heavy.”

THERE IS NOTHING WRONG WITH ME, and they act like there is. It’s totally for aesthetic reasons, and it’s fat-shaming. Plain and simple. I like myself, and I do my best to take care of myself.

This post really opened my eyes and is changing the way I’m seeing exercise, eating, and my weight. I’m shocked! I was aware that the BMI wasn’t a super accurate measure, but I was still using it as a rough guide to how healthy my weight was. This, above anything else I’ve read about weight, body size, and health, is opening my eyes to the true importance of LISTENING to MY body.

While there is a valid message, you have complete falsities throughout this article. The definitions of BMI have thousands of studies to back it up. I’ve worked at the CDC and am now a practicing physician. BMI > 85th %ile is overweight and > 95 is obese. It’s a huge problem resulting in an increase in disease and mortality. Eating disorders are also a problem but that doesn’t change the fact that obesity is a growing problem. Moderation in all things including an active lifestyle and a well balanced diet is healthy for all.
JJ, MD/MPH

B.R….you are a breath of fresh air!!! I’ve come to the same conclusions personally about health v. weight and shout it to my personal circle and take any opportunity to tell my weight and age to break these stigma , and now you’ve done the research and can reach far far further than me alone. I LOVE YOU!!!!! THANK YOU!!! And you can bet since I found you today, I’ll be on A.LOT,! Especially as I work with my health classes and girls at school!
Maria==age 37, 5’6″ish, about 180 pounds ( I stopped looking at the scale long ago).

Yes! Thank you Maria! The people who are the biggest proponents are those who have seen the discrepancy between appearance and fitness firsthand — whether because they don’t look like beauty ideals but ARE healthy, or because they’re health/fitness professionals who see that every single day. So glad you found us! Thank you for your help spreading the word!

I’m tall and have never had to make an effort to exercise or eat healthfully to maintain a “healthy” BMI. But I’m not healthy. I don’t have an eating disorder, but I do have low energy and my resting heart rate is terrible. I’ve even been afraid that if I start exercising it might throw off whatever magic-juju-metabolism I’ve got going on. Your posts have given me the confidence to start exercising and love my body no matter what the outcome.

Good grief! The BMI is SO poor a measurement that it may as well be based on a single person whom we all have to ‘measure’ up to. No gaining weight after 25?! I had to stop reading for a minute after that one. No accounting of body type, ethnicity, gender, age…a more obvious piece of diet-industry propaganda surely never there was, and yet it persists. It might as well require that one’s eyes turn gray after midnight and then green by dawn. Just insane, all around. (I did know about the overnight obesity epidemic, but had read that there was a connection to someone in the Jenny Craig or Weight Watchers empire?)